PERIOPERATIVE GRAND ROUNDS
May I Have Another?d Medication Error THE CASE A 40-year-old man who was a pharmacology-trained researcher with a doctorate was admitted to the hospital after a seizure. The patient said that this was his ﬁrst seizure; results from a review of symptoms and physical examination were unremarkable. He denied use of alcohol, caffeine products, and other recreational drugs; his only regular medication was multivitamins. However, he stated that he had difﬁculty falling asleep and this had substantially increased in the past few weeks. He had ﬁnally self-referred to a local sleep disorder program, where he was given a prescription for zolpidem. The label instructions read, “Zolpidem 10 mg, 1 at bedtime; if ineffective, take another.” Based on his interpretation of these instructions, the patient said he had been regularly taking up to 10 tablets of zolpidem every night until running out of medication. A few days after abruptly stopping the medication, he experienced the seizure.
DISCUSSION Poor patient awareness or inadequate understanding of medication risks and instructions are often cited as a cause of medication errors and adverse drug events. This ﬁnding is not surprising because patients often lack sufﬁcient information for proper medication use. As this case highlights, even an individual with pharmacological training can make a misstep that came at a substantial cost. This case is a symbol of patients’ reliance on pill bottle labels as a source of crucial information. Physicians often fail to review even basic medication information with patients at the time of prescribing.1,2 This is unfortunate because patients who report having medicationrelated discussions with their provider are more likely to take medication as prescribed. Although the health care system limits time for the physician to spend with patients, patients rely on their doctors to tell them important medication information. This patient left the sleep clinic with a prescription for zolpidem but evidently received no counseling. When dispensing
medications, pharmacists frequently fail to counsel patients on safe medication use, despite federal and state mandates to do so.3,4 Furthermore, pharmacists may not be fully aware of why a patient was prescribed the medication, limiting the potential effectiveness of pharmacist counseling. A pharmacy practice can be very busy, and patients may not ﬁnd it easy to ask for information because privacy can also be a problem. In this case, the patient received misleading instructions on the bottle and may not have received or read other instructions. The label instruction “Zolpidem 10 mg, 1 at bedtime; if ineffective, take another” allows misinterpretation as to how often the user can repeat the dose and over what time interval. The patient might have also received from the pharmacy a package insert, a container label with auxiliary warnings, and a medication guide mandated by the US Food and Drug Administration for zolpidem. It is unknown if the patient read them, but research has repeatedly shown that print materials are unnecessarily complex and difﬁcult to understand or interpret.5,6 While errors can take place regardless of education or health literacy, disparities do exist. Patients with limited literacy skills, with multiple comorbidities, and who are elderly face the greatest risk. Limited literacy skills are associated with poor recall of medication names and inadequate understanding and use of medication instructions and precautions.7-10
continued on page 517 This content is adapted from AHRQ WebM&M (Morbidity & Mortality Rounds on the Web) with permission from the Agency for Healthcare Research and Quality. The original commentary was written by Michael Wolf, PhD, MPH, and was adapted for this article by Nancy J. Girard, PhD, RN, FAAN, consultant/owner, Nurse Collaborations, Boerne, TX. (Citation: Wolf M. May I Have Another?dMedication Error. AHRQ WebM&M [serial online]. http://webmm .ahrq.gov/case.aspx?caseID¼327. Published June 2014. Accessed June 1, 2015.) Dr Girard has no declared afﬁliation that could be perceived as posing a potential conﬂict of interest in the publication of this article. http://dx.doi.org/10.1016/j.aorn.2015.08.016 ª AORN, Inc, 2015
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continued from page 556 How can cases like this one be prevented? One suggestion is use of a Health Literate Care Model,11 which assumes that all patients have information needs. Physicians need to provide spoken counseling at the time of prescribing a medication and consider the route used to write prescriptions. E-prescribing has default instructions at the time of order. Electronic health record tools help standardize prescribing and structure physician counseling.12-14 Several bodies detail best practices for patient-centered prescription labeling.15,16 Reducing variability and vagueness of instructions limits confusion. For example, a universal medication schedule approach promotes using more explicit times per day (eg, morning and bedtime instead of twice daily) and specifying spacing intervals (eg, wait an hour before taking again) and maximum daily dose (eg, do not take more than two 5-mg tablets). However, in the end, the solution must involve the entire continuum of prescribing and dispensing medication, as well as an effort to activate patients to take a role in their own care and ask questions and stay informed.
PERIOPERATIVE POINTS Patients may not receive necessary physician and pharmacist counseling for prescribed medications. Medication labels can be vague, incomplete, or incorrect. Patients should always ask about their medication, including what it is for, how it should be taken, how it will treat their condition, and if there is anything else they should know about their medication. Pharmacists should ensure that patients receive appropriate information and should review instructions for use and precautions with patients.
References 1. Tarn DM, Heritage J, Paterniti DA, Hays RD, Kravitz RL, Wenger NS. Physician communication when prescribing new medications. Arch Intern Med. 2006;166(17):1855-1862. 2. Serper M, McCarthy DM, Patzer RE, et al. What patients think doctors know: beliefs about provider knowledge as barriers to safe medication use. Patient Educ Couns. 2013;93(2):306-311.
Perioperative Grand Rounds 3. Tarn DM, Paterniti DA, Orosz DK, Tseng CH, Wenger NS. Intervention to enhance communication about newly prescribed medications. Ann Fam Med. 2013;11(1):28-36. 4. Svarstad BL, Bultman DC, Mount JK. Patient counseling provided in community pharmacies: effects of state regulation, pharmacist age, and busyness. J Am Pharm Assoc (2003). 2004;44(1): 22-29. 5. Wolf MS, King J, Wilson EA, et al. Usability of FDA-approved medication guides. J Gen Intern Med. 2012;27(12):1714-1720. 6. Wallace LS, Roskos SE, Weiss BD. Readability characteristics of consumer medication information for asthma inhalation devices. J Asthma. 2006;43(5):375-378. 7. Wolf MS, Davis TC, Tilson HH, Bass PF III, Parker RM. Misunderstanding of prescription drug warning labels among patients with low literacy. Am J Health Syst Pharm. 2006;63(11): 1048-1055. 8. Davis TC, Wolf MS, Bass PF III, et al. Literacy and misunderstanding prescription drug labels. Ann Intern Med. 2006;145(12): 887-894. 9. Davis TC, Wolf MS, Bass PF III, et al. Low literacy impairs comprehension of prescription drug warning labels. J Gen Intern Med. 2006;21(8):847-851. 10. Persell SD, Osborn CY, Richard R, Skripkauskas S, Wolf MS. Limited health literacy is a barrier to medication reconciliation in ambulatory care. J Gen Intern Med. 2007;22(11):1523-1526. 11. Koh HK, Brach C, Harris LM, Parchman ML. A proposed ‘Health Literate Care Model’ would constitute a systems approach to improving patients’ engagement in care. Health Aff (Millwood). 2013;32(2):357-367. 12. Bailey SC, Persell SD, Jacobson KL, Parker RM, Wolf MS. Comparison of handwritten and electronically generated prescription drug instructions. Ann Pharmacother. 2009;43(1):151-152. 13. Bergeron AR, Webb JR, Serper M, et al. Impact of electronic prescribing on medication use in ambulatory care. Am J Manag Care. 2013;19(2):1012-1017. 14. Morrow DG, Conner-Garcia T, Graumlich JF, et al. An EMR-based tool to support collaborative planning for medication use among adults with diabetes: design of a multi-site randomized control trial. Contemp Clin Trials. 2012;33(5):1023-1032. 15. USP32 general notices and requirements. US Pharmacopeial Convention. http://www.usp.org/sites/default/ﬁles/usp_pdf/EN/ USPNF/generalNoticesandRequirementsFinal.pdf. Accessed July 23, 2015. 16. Title 16. Board of Pharmacy proposed language. California Department of Consumer Affairs Board of Pharmacy. http:// www.pharmacy.ca.gov/laws_regs/1707_5_proposed_text.pdf. Accessed July 23, 2015.
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